A thesis submitted in fulfillment of the requirement for the degree of Doctor of Philosophy in Sociology and

“NOT JUST A MISCARRIAGE”:

THE SOCIAL AND CULTURAL PERSPECTIVES OF MISCARRIAGE AMONG URBAN MALAY WOMEN

BY

NURULWAHIDA BINTI SAAD

A thesis submitted in fulfillment of the requirement for the degree of Doctor of Philosophy in Sociology and

Anthropology

Department of Philosophy in Sociology and Anthropology Kulliyyah of Islamic Revealed Knowledge and Human

Sciences

International Islamic University Malaysia

SEPTEMBER 2018

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ABSTRACT

This study explores the social and cultural perspectives of miscarriage among urban Malay women. The objectives of the study included examining the meanings, beliefs, rituals, health seeking behaviour and the role of health care systems in dealing with miscarriage. The study adopted a qualitative approach that included in-depth interviews using a multi-sited ethnography and participant observation. The fieldwork was conducted over a period of 13 months from April 2014 until May 2015. 30 primary informants were selected purposively and were of Malay ethnicity, working and residing in the Klang Valley and had at least one experience of miscarriage. Two focus group discussions (FGDs) were also conducted with women with no experience of miscarriage and in-depth interviews conducted with three medical doctors. The interviews were audio recorded, transcribed and translated into English and the data analysed using thematic analysis. Two major themes emerged: (1) the sacred side of miscarriage and; (2) miscarriage as an interpersonal event. The first theme explores the sanctifying behaviours, attitudes, and beliefs associated with miscarriage rooted in the informants meanings of pregnancy and the Adāt and Islamic characteristics of Malay culture. Findings revealed that Malay women attributed miscarriages to a number of factors including cultural food beliefs, God's will, the evil eye and jinn, work and lifestyle factors such as physical activity, stress and emotional upset. The sacredness of miscarriage was also evident in the food prohibitions and cleanliness and ‘dirt’

avoidance rituals practiced in the post-miscarriage confinement practices. The second theme explores miscarriage as an interpersonal event where the people the informants interacted with shaped and impacted how she experienced her miscarriage. Good doctor-patient relationships, supportive husbands and comforting friends and family all helped the informants cope with their personal reactions and emotional responses to their miscarriage. These positive social support systems helped console, remind and encourage the informants to develop self coping strategies by connecting with their Islamic and spiritual beliefs and practices. Incidences of negative or insensitive reactions from others were found to be due to lack of personal experience, knowledge and understanding of miscarriage which in turn shaped miscarriage as a social stigma.

The study concludes that miscarriage is more than just a physiological event but is also a lived experience governed by social, cultural, religious and medical frameworks. By understanding miscarriage within the socio-cultural Malay context, we can enhance healthcare systems to fill the gap between culture and medicine by substantiating Malay cultural guidelines as points of reference to provide culturally relevant policies for comprehensive and holistic medical management of miscarriage. This includes creating awareness and organising campaigns for the importance of antenatal education, and an increased sensitivity towards women who experience miscarriage. In addition, suggestion of a collaboration between traditional healers, healthcare providers and counsellors to provide post-miscarriage physical and psychological care for women who have miscarried, may promote healthy healing and coping for women after miscarriage.

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ثحبلا ةصلاخ

ةساردلا هذه علطتست تلشمو .ةيرضلحا قطانلما في ويلالما ءاسنلا ينب ضاهجلإل ةيفاقثلاو ةيعامتجلاا ةرظنلا

لا كولسو ،سوقطلاو ،تادقتعلماو ،ميهافلما ةساردلا فادهأ صحف

في ةيحصلا ةياعرلا مظن رودو ،يحصلا

ذلا يعونلا جهنلما ةساردلا تدمتعا .ضاهجلإا عم لماعتلا ايفارغونثلإا مادختساب ةقمعتلما تلاباقلما لشم ي

في نياديلما لمعلا لامكتسا تمو .ينكراشلما ةظحلامو بناولجا ةددعتلما ليربأ نم ،اًرهش 13

2014 ويام تىح

2015 رايتخا تمو . 30

تابرمخ هو ةيدصق ةقيرطب ن

هيدلو جنلاك يداو في نميقيو نلمعي ،ويلام لصأ نم ن

ا ىلع ةدحاو ةبرتج ةبرخ نهيدل سيل ءاسن نم ينتعوممج عم ةزكرم ةشقانم ءارجإ تم امك .ضاهجلإا في لقلأ

.ءابطأ ةثلاث عم ةقمعم تلاباقمو ،ضاهجلإا في ةيزيلنجلإا لىإ اهتجمرتو اهغيرفت ثم ايتوص تلاباقلما ليجست تمو

ناسيئر نارمأ ليلحتلا نم رهظو .يعوضولما ليلحتلا مادختساب تانايبلا ليلتح تمو ( :

1 سدقلما بنالجا )

،ضاهجلإل (

2 رملأا فشكيو .صاخشلأا ينب ةلاح وه ضاهجلإا ) ،فقاولماو ،سيدقتلا كولس لولأا

برخلما موهفم في رذجتلما ضاهجلإاب ةطبترلما تادقتعلماو تا

ةفاقثلل ةيملاسلإا صئاصلخاو تاداعلاو ،لملحا نع

ح بنسن تايولالما ءاسنلا نأ جئاتنلا رهظتو .ةيويلالما تادقتعلما ةفاقث لمشت لماوع ةدع لىإ ضاهجلإا تلاا

،للها ةدارإو ،ماعطلا في و

ةريرشلا ينعلا ،

جاعزنلااو رتوتلاو ،نيدبلا طاشنلا لثم ةايلحا طنمو ،لمعلاو ،نلجاو

سراتم تيلا خاسولأا بنتجو ةفاظنلاو ماعطلا رظح في اًضيأ ةحضاو ضاهجلإا ةيسدق تناك امك .يفطاعلا يف لإا دعب ام ثيح يصخش ثدحك ضاهجلإا نياثلا رملأا فشكيو .ضاهج

لماعتي ثدلحا عم صاخشلأا

.ضاهجلإا عم اهتبرتج ةقيرط في اورثأو ءاقدصلأاو ينمعادلا جاوزلأاو ،ضيرلماو بيبطلا ينب ةديلجا تاقلاعلا نأو

،ةرسلأاو ينساولما دعاسي لكلا

برخلما تا باجتساو ةيصخشلا لاعفلأا دودر عم لماعتلا ىلع ةيفطاعلا نهت

برخلما عيجشتو يركذتو طبض ىلع ةيبايجلإا يعامتجلاا معدلا ةمظنأ تدعاس دقو .ضاهجلإل تا

ريوطتل

تهادقتعم عم لصاوتلا للاخ نم تاذلا عم لماعتلا تايجيتاترسا ن

تهاسراممو ن تدجو دقو .ةيملاسلإاو ةيحورلا

صقن ببسب نيرخلآا نم ةساسح يرغ وأ ةيبلس لاعفأ دودر تلااح ضاهجلإا مهفو ،ةيصخشلا ةبرلخاو ةفرعلما

،يجولويسيف ثدح درمج نم رثكأ ضاهجلإا نأ لىإ ةساردلا صلتخو .ضاهجلإاب ايعامتجا فصوي هرودب يذلا قايسلا نمض ضاهجلإا مهف للاخ نمو .ةيبطو ةينيدو ةيفاقثو ةيعامتجا رطأ اهمكتح ةيح ةبرتج اًضيأ لب ننكيم ،فياقثلا يعامتجلاا يزيلالما دسل ةيحصلا ةياعرلا ةمظنأ زيزعت ا

للاخ نم بطلاو ةفاقثلا ينب ةوجفلا

ةلص تاذ تاسايس يرفوتل ةيعجرم طاقنك ةيزيلالما ةيفاقثلا ةيهيجوتلا ئدابلما تابثإ اب

ةلماشلا ةيبطلا ةرادلإ

تج ةيساسلحا زيزعتو ،ةدلاولا لبق ميلعتلا ةيهملأ تلاحم ميظنتو يعو دايجإ لمشي اذهو .ضاهجلإل ءاسنلا ها

ةيحصلا ةياعرلا يمدقمو ينيديلقتلا ينلجاعلما ينب نواعتلا يدؤي دق ،كلذ لىإ ةفاضلإاب .ضاهجلإاب نررم تياوللا

يحصلا ءافشلا زيزعت لىإ ،نضهجأ تياوللا ءاسنلل ضاهجلإا دعب ةيسفنلاو ةيدسلجا ةياعرلا يمدقتل نيراشتسلماو

اعتو

في

.ضاهجلإا دعب ءاسنلا

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APPROVAL PAGE

The dissertation of Nurulwahida Binti Saad has been approved by the following:

_____________________________

Assoc. Prof. Dr. Noor Azlan Mohd. Noor Supervisor

_____________________________

Asst. Prof. Dr. Nor Azlin Tajuddin Co-Supervisor

_____________________________

Prof. Dr. A.H.M. Zehadul Karim Internal Examiner

_____________________________

Prof. Dr. Sekh Rahim Mondal External Examiner

_____________________________

Prof. Fakrul Islam External Examiner

_____________________________

Assoc. Prof. Dr. Ismaiel Hassanein Ahmed Mohamed Chairman

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DECLARATION

I hereby declare that this dissertation is the result of my own investigations, except where otherwise stated. I also declare that it has not been previously or concurrently submitted as a whole for any other degrees at IIUM or other institutions.

Nurulwahida Binti Saad

Signature ... Date ...

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OP

INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

DECLARATION OF COPYRIGHT AND AFFIRMATION OF FAIR USE OF UNPUBLISHED RESEARCH

“NOT JUST A MISCARRIAGE”: THE SOCIAL AND CULTURAL PERSPECTIVES OF MISCARRIAGE AMONG

URBAN MALAY WOMEN

I declare that the copyright holders of this dissertation are jointly owned by the student and IIUM.

Copyright © 2018 Nurulwahida Binti Saad and International Islamic University Malaysia. All rights reserved.

No part of this unpublished research may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior written permission of the copyright holder except as provided below

1. Any material contained in or derived from this unpublished research may be used by others in their writing with due acknowledgement.

2. IIUM or its library will have the right to make and transmit copies (print or electronic) for institutional and academic purposes.

3. The IIUM library will have the right to make, store in a retrieved system and supply copies of this unpublished research if requested by other universities and research libraries.

By signing this form, I acknowledged that I have read and understand theIIUM Intellectual Property Right and Commercialization policy.

Affirmed by Nurulwahida Binti Saad

……..……….. ………..

Signature Date

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ACKNOWLEDGEMENTS

One of the major reasons I chose to dedicate the last 6 or so years to medical anthropology was to take a temporary break from working on what it means to be a human being and to discover what being human is all about. If I have learnt anything from this experience, it's that nothing is "just is" and this was not just a PhD. I may have come away more qualified, more skilled and a more intellectual scholar but if anything, I believe it has allowed me to become a better version of myself. We don't grow when things are easy, we grow when we face challenges. First, I wish to express my sincere appreciation and thanks to my informants who generously shared their time and experiences of heartbreak but who also showed that adversity comes with blessings.

Without them, my thesis wouldn’t be my first greatest academic accomplishment and my inspiration for many more. I would like to thank my supervisor Assoc. Prof. Dr.

Noor Azlan Mohd. Noor who saved me at a time when I felt amiss. I am indebted to him for patiently waiting for me to evolve into a true writer in anthropology. He always had confidence in my scholarly ability and my perseverance, even when I seriously doubted it, but generously devoted his time and wisdom to nurture me during my thesis writing. I would also like to acknowledge Assoc. Prof. Dr. Rohaiza Rokis, who has provided invaluable support to me throughout my postgraduate studies as my lecturer, department head, colleague and dear friend. Your calmness and composure will always be something I aspire to be. My journey would be solemn without my dear friends and confidantes who cheerfully listened to my woes and sorrows and rejoiced in my small triumphs along the way. My heartfelt thanks goes to my course mates Qonita Basalamah, Iyad Eid, Dewan Mahboob Hussain, Andree Armilis, Adam Andani, Mohamad Adha Shaleh and Faiza Mohd Fakhruddin who gave me good reason to attend all those classes and look forward to the post-class rendezvous. May our friendships prosper beyond our graduation. A special thanks goes to my best friend Nadia Anuar who never let me get lonely or hungry. My fellow super mummies Szariannie Sulaiman and Tanja Jonid who shared with me their spirit as mums that study. Finally, it is my utmost pleasure to dedicate this work to my family. To my dear parents, I thank you for always supporting me and caring for me when times got tough. I will forever be indebted to you for loving your granddaughters when I was too busy. May this PhD give me the opportunity to make the rest of your lives more comfortable. I am deeply grateful to my husband and two girls who granted me the gift of their unwavering belief in my ability to accomplish this goal. Though we spent most of our married and parental lives apart, your spirit and existence reminded me that there is life besides a PhD. I was and will always be inspired by your everlasting support and patience.

Without the practical support, love, encouragement, and prayers of my friends, family, and colleagues I may not have finished. But all praises to Allah for blessing me with the opportunity, strength and endurance to actually finish.

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TABLE OF CONTENTS

Abstract ... ii

Abstract in Arabic ... iii

Approval Page ... iv

Declaration ... v

Copyright Page ... vi

Acknowledgements ... vii

List of Tables ... x

List of Figures ... xi

CHAPTER ONE: INTRODUCTION ... 1

1.1 Background of the Study ... 1

1.2 Statement of the Problem... 4

1.3 Significance of the study ... 7

1.4 Research Objectives... 7

1.5 Research Questions ... 8

1.6 Research Methodology ... 8

1.6.1 The Study Area ... 8

1.6.2 Fieldwork ... 11

1.7 Chapter Outlines ... 23

CHAPTER TWO: LITERATURE REVIEW ... 25

2.1 Introduction... 25

2.2 The Biomedical Framework ... 26

2.3 The Socio-cultural Framework ... 29

2.3.1 Nomenclature and Cultural Meaning of Miscarriage... 29

2.3.2 Cultural Beliefs ... 30

2.3.3 Rituals in Miscarriage ... 44

2.4 Women’s Experience of Miscarriage ... 48

2.4.1 The Emotional Consequences of Miscarriage... 48

2.4.2 Coping with Miscarriage ... 52

2.4.3 Miscarriage as an Ambiguous Loss ... 56

2.5 An Overview of Theoretical Orientations ... 66

2.5.1 Theoretical Frameworks... 67

2.6 Conclusion ... 71

CHAPTER THREE: THE SACRED SIDE OF MISCARRIAGE ... 73

3.1 Introduction... 73

3.2 The Informants’ Experience of Miscarriage ... 74

3.2.1 The Meaning of the Pregnancy ... 74

3.2.2 Signs and Symptoms of the Miscarriage ... 77

3.2.3 The Emotional Journey ... 78

3.3 Explaining the Miscarriage ... 87

3.3.1 Medical Explanations ... 88

3.3.2 Work Environment ... 89

3.3.3 Food Taboos and Cultural Beliefs... 90

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3.3.4 Islamic Beliefs ... 95

3.3.5 Jinns, Al-Ain and Saka ... 97

3.4 Management and Healing ... 100

3.4.1 Medical Treatment ... 100

3.4.2 Burial Rituals ... 102

3.4.3 The Pantang ... 103

3.5 Surviving the Hardship ... 106

3.5.1 Seeking Knowledge ... 107

3.5.2 Social Support ... 108

3.5.3 Coping Through Virtual Expression ... 110

3.5.4 Coping Through Distraction ... 112

3.5.5 Religious Coping ... 113

3.6 Conclusion ... 115

CHAPTER FOUR: MISCARRIAGE AS AN INTERPERSONAL EVENT 120 4.1 Introduction... 120

4.2 Healthcare Staff ... 121

4.2.1 Treatment from Doctors ... 121

4.2.2 Treatment from Nurses ... 128

4.3 Supportive Husbands ... 131

4.4 Friends, Family and Others ... 136

4.4.1 Family ... 136

4.4.2 Friends ... 137

4.4.3 Reactions of Others ... 139

4.5 Conclusion ... 143

CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS ... 150

REFERENCES ... 160

GLOSSARY ... 176

APPENDIXES ... 180

Appendix A: Informant Information Sheet ... 180

Appendix B: Informant Consent Form ... 181

x

LIST OF TABLES

Table No. Page No.

1.1 The socio-demographic and miscarriage details of the 30 13 informants selected for the study

1.2 Interview Schedule 18

3.1 List of food prohibitions and associated cultural beliefs 94

3.2 Coping strategies used among informants 110

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LIST OF FIGURES

Figure No. Page No.

1.1 The location of the Klang Valley in Peninsular Malaysia 9

1.2 The Klang Valley and its conurbation 10

1.3 Example of the coding process. 22

1.4 Grand themes and sub-themes determined from findings. 22

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CHAPTER ONE INTRODUCTION

1.1 BACKGROUND OF THE STUDY

For most women, pregnancy is a defining moment, symbolising a woman’s dreams, hopes and wishes of becoming a mother and nurturing a child. The lyric from an American children’s playground song, “first comes love, then comes marriage, then comes baby in a baby carriage”, may apply in some instances, but not in others. For some women, miscarriages happen and the so-called normative life progression is delayed.

The American College of Obstetricians and Gynaecologists (ACOG, 2015) define miscarriage as an early loss of pregnancy during the first thirteen weeks of pregnancy and is also known medically as a spontaneous abortion. According to The American Pregnancy Association (APA, 2017), approximately 10–25% of clinically recognized pregnancies end in miscarriage and defines it as the natural and spontaneous termination of a pregnancy within 20 weeks of gestation. Alternatively, Mehta and Pattanayak (2013) define miscarriage as the premature loss of a foetus up to 23 weeks of pregnancy and weighing up to 500 grams. Evidently, definitions of miscarriage appear to vary between countries depending on its local prevalence and reports. In the local context, Malaysia’s Foetal Medicine and Gynaecology Centre (FMGC, 2005) define miscarriage as the spontaneous loss of a baby before the 24^th week of pregnancy, which is most likely to take place in the first trimester, that is within the first 10-12 weeks of pregnancy. They also reported that miscarriages occur in approximately 10-

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20% of all pregnancies and it is not unexpected that many women will experience a miscarriage at least once in their lifetime.

The prevalence of miscarriage across populations has secured it as a prevailing topic of investigation in medical studies. Studies into the medical causes of miscarriage attribute it to genetic, endocrine, autoimmune, and thrombotic abnormalities.

Epidemiological studies identify smoking, alcohol consumption, coffee drinking, and environmental chemical exposure during pregnancy, as potential risks for miscarriage.

In Malaysia, increasing age, a woman’s career, obesity, and dengue infection were found to be significant risk factors for miscarriage (Tan et al., 1995; Mohd Sidik &

Rampal, 2009; Tan et al., 2012).

The early stages of a pregnancy is a period in which a woman learns to embrace her pregnancy and connect emotionally with her growing baby. Since miscarriages often take place during the early stages of a pregnancy, a miscarriage is, thus, expected to affect her emotional well-being (Gerber-Epstein et al., 2009). Studies have shown that women who have experienced miscarriage often find it a traumatic experience that comes with feelings of loss, grief, guilt, depression, anxiety, and stress. These responses though experienced individually, reflect the woman’s thwarted plans of motherhood, a loss of sense of self, and the shattering of her hopes and dreams for the future in her family and society (Lee & Slade, 1996; Layne, 1997; Brin, 2004; Lok & Neugebauer, 2007). Thus, it is conceivable that a miscarriage is not just a biological phenomenon but an experience that is subject to social influences and perceptions, so much so that many studies have shown miscarriage to be an isolating experience, that is socially stigmatised, socially and culturally silent, and hidden in secrecy (Layne, 1997; Van den Akker, 2011; Peel & Cain, 2012). Such evidence suggests that miscarriage exists beyond medical understanding and is a socially significant health issue. Studies have

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also shown how the degree of appropriate care and attention given to a woman following her miscarriage has significant impacts on her health and well-being (Swanson, 1999; Geller et al., 2010; McLean & Flynn, 2013).

Other themes observed in miscarriage studies are the issues of foetal personhood (James, 2000; Keane, 2009; Porter, 2015) and the ambiguity surrounding the meaning of miscarriage as a seemingly unexplainable event (Betz & Thorngren, 2006; Murphy

& Philpin, 2010). Such themes are part and parcel of Layne’s (1990) description of miscarriage and pregnancy loss as an ‘incomplete rite of passage’. Where social norms consider pregnancy and birth as rites of passage, a miscarriage aborts the process of becoming complete adults and leaves parents without any status as fathers or mothers (Reinharz, 1988; Layne, 1990).

According to Callister (2006), miscarriage is intimately related to one’s culture.

Specifically, cultures that place a high value on having children, see miscarriage as a very significant and painful experience for those involved, particularly for the parents, and as such require healers and spiritual guidance to help a couple recover from their loss. In Western culture, however, there are no rituals and established means which recognises and commemorates miscarriages. In effect, this cultural denial of miscarriage denies the existence of a child (in the pregnancy) and undervalues the importance of the loss (Layne, 2000).

Ultimately, a miscarriage, scientifically, does not conform to the medical norms of correct reproductive processes, even though the above-mentioned issues indicate that miscarriage exists beyond medical understanding and is a legitimate experience of loss and grief that is shaped by social and cultural perspectives. This study aims to conceptualise miscarriage and understand its social and cultural significance within the Malay context.

4 1.2 STATEMENT OF THE PROBLEM

Arjunan (2016) writes about the common myths associated with miscarriage embedded in the Malaysian community. He describes how myths, such as stress and heavy lifting during pregnancy, are commonly believed to cause a miscarriage, and because of such cultural beliefs, it provokes some women to resort to keeping silent about their miscarriage to avoid having people make judgments about them or blame them for their miscarriage. While facts and myths are culturally symbolic, it obstructs the opportunity to provide a more supportive environment for couples who may be grieving over a miscarriage.

The perspective that miscarriage is often experienced in secrecy and silence was also recently addressed by Facebook founder, Mark Zuckerberg. Upon announcing his wife’s pregnancy after three miscarriages, he referred to the stigma associated with miscarriages, as though it is the fault of the parents. He described his miscarriage experience as “a lonely experience” because it somehow cannot be talked about openly and honestly. Referring to a national (U.S.) survey on public perceptions of miscarriage, one of the lead authors described how talking about miscarriage is still very much a taboo subject for public discussion (Bardos, et al., 2015).

Several studies revealed that between 25% and 50% of women who have experienced a miscarriage, find it significantly distressing that elicits deep and emotional responses that are comparable to post-traumatic symptoms such as stress, grief, depression, guilt, and self-blame, that also requires time to recover from (Nikcevic et al., 1998; Broen et al., 2005; Lee & Rowlands, 2015).

Several studies investigating the clinical treatment of miscarriages in hospitals have also shown that the emotional responses of miscarriage are shaped and exacerbated by unsatisfactory healthcare received by women that accorded them little compassion,

5

empathy, and sensitivity towards their miscarriage. In addition, the lack of adequate medical explanation given to the women following their miscarriage served to make the unexpected miscarriage an upsetting and confusing situation for the women to understand and accept (Friedman, 1989; Tsartsara & Johnson, 2002; McClean & Flynn, 2013). Scholars, such as Athey and Spielvogel (2000), have proposed that medical personnel should approach women who have miscarried with more sensitivity and should provide information about the causes and implications of miscarriage to avoid promoting increased anxiety and other psychiatric symptoms for the women. Such evidence indicates that healthcare systems are integral to women’s miscarriage experience.

Studies exploring miscarriage experience among Malays in light of emotional reactions and professional health care roles are scarce. Many studies have explored the beliefs and practices related to pregnancy and childbirth in Malay culture (Chen, 1973;

Wilson, 1973; Manderson, 1981; Laderman, 1987). However, discussions of adverse pregnancy outcomes, such as miscarriage, are mentioned fleetingly and often in relation to Malay food beliefs about miscarriage. Studies into the attitudes, emotional consequences, meaning, beliefs, and practices in miscarriage in the Malay context are less well developed. However, a study by Sherina et al. (2008) revealed a significant association between depressive symptoms and a history of having a miscarriage, whereby women who had suffered a miscarriage within the last six months were five times more likely to develop depressive symptoms compared to women who did not suffer from any miscarriage. This indicates the likelihood that Malay women may exhibit similar emotional responses to miscarriage as reported in previous studies. It is also possible that any suffering that may be experienced by Malay women, may be

6

compounded by local healthcare systems, as well as an unspoken social and cultural taboo that influences her miscarriage experience and coping processes.

Malay women’s perceptions, understanding, and attitudes towards miscarriage as an adverse pregnancy outcome, and how these affect health-seeking behaviour, has received scant research attention. Ariff and Beng (2006), report that Malaysians’

perception of health and illnesses, healthcare expectations, as well as treatment choices are often heavily coloured by their cultural beliefs and practices. In relation to this, the concept of health and illness, particularly in response to miscarriage, needs to be understood in a wider cultural system of values.

As the precursor and antithesis for miscarriage, pregnancy and birth, respectively, are culturally patterned, and women’s knowledge, beliefs and behaviours are shaped by a cultural context (Laderman, 1983; Balin, 1988). With regards to emotional responses, Kleinman (1992) has described how anthropological studies have shown that the experience of suffering is not only personal but is deeply influenced by culture and its particular moral world. With this in mind, this study attempts to explore the cultural understandings of miscarriage as derivative from the underlying intellectual orientation of the Malay culture. This study is based on a study of Malay women, working and living in an urban environment, who have had at least one experience of miscarriage. It examines the personal and cultural meanings ascribed to miscarriage and the social understanding of miscarriage as occurred in the Malay context. Issues pertaining to pregnancy interventions, such as food beliefs, are also included as part of the way in which cultural constructions of miscarriage are framed in Malaysia.

Understanding the local perception of miscarriage with regards to belief and practices, social stigma, rights to disclosure, and public reaction are essential to improve health services, as well as promote a social sensitivity towards miscarriage.

7 1.3 SIGNIFICANCE OF THE STUDY

Reflecting on the findings that women are five times more likely to develop depressive symptoms following a miscarriage should be a cause for concern. It motivates the need for a local and modern study of miscarriage to provide details about Malay women’s experience of miscarriage. This study is important for a number of reasons. Firstly, findings from this study aim to add to the existing corpus of knowledge with regards to miscarriage in Malaysia, particularly among the Malays. Secondly, the study aims to understand miscarriage using both biomedical and socio-cultural approaches. This is significant particularly in analysing and understanding issues surrounding miscarriage that are related to education, economy, and cultural beliefs and practices. Thirdly, through our understanding of miscarriage, we can fill the gap between culture and medicine by substantiating Malay cultural guidelines as points of reference to provide culturally relevant policies for comprehensive and holistic medical management.

Lastly, by understanding the emotional reactions to the event and the relevance of coping and practices following a miscarriage, we can better understand the challenges faced by women who have suffered a miscarriage in a society that upholds a cultural silence on the subject.

1.4 RESEARCH OBJECTIVES

The research aims at achieving the following objectives:

1. To explore the meanings, beliefs, and practices related to miscarriage among urban working Malay women who have experienced miscarriage.

2. To examine the coping strategies employed by the women following their miscarriage.

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3. To determine the role and impact of healthcare professionals in miscarriage.

1.5 RESEARCH QUESTIONS

The research questions which are dealt with in this research are as follows:

1. What are the meanings, beliefs, and practices related to miscarriage among urban working Malay women who have experienced miscarriage?

2. What coping strategies are employed by the women following their miscarriage?

3. What is the role and impact of healthcare professionals in miscarriage cases?

1.6 RESEARCH METHODOLOGY 1.6.1 The Study Area

In this study, data was collected throughout several locations within the Klang Valley, or locally known as Lembah Klang. Being situated between the northern and southern regions of Peninsular Malaysia has made the Klang Valley the core economic and financial entity of Peninsular Malaysia (see Figure 1.1).

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Federal Territory Development and the Klang Valley Planning Division (2004)

The valley is named after the Klang River, the principal river that flows through it which starts at Port Klang and ends at Hulu Klang and is closely linked to the early development of the area as a cluster of tin mining towns in the late 19^th century. The Klang Valley region centres around the Federal Territory of Kuala Lumpur, considered to be the capital, financial, and commercial centre of Malaysia. The Klang Valley also comprises of other corresponding local authorities (Figure 1.2). As of 2012, the Klang Valley is home to roughly 7.9 million people. With approximately 2,000 residents per

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square kilometre, the Klang Valley comprises the densest urbanised area in Malaysia (Dziauddin et al., 2015).

Figure 1.2 The Klang Valley and its conurbation.

Source: The Federal Territory Development and the Klang Valley Planning Division (2004)

In 2010, the Malaysian Prime Minister, Datuk Seri Najib Razak, coined a new name for the Klang Valley called the Greater Kuala Lumpur, to popularise the area as the capital and commercial heart of the country that boasts a thriving business infrastructure and flourishing liveability. It is also home to generations that originate or are descended from Malaysia’s 13 states (Negeri) and three federal territories (Wilayah

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Persekutuan). As such, the Klang Valley is also famed for its melting pot of cultures and traditions.

1.6.2 Fieldwork

My ethnographic fieldwork took place throughout several locations within the Klang Valley, such as Shah Alam, Bangi, Cheras and Rawang. It began in early April 2014 and continued over a period of 13 months, until it ended in May 2015. The fieldwork was a qualitative study which involved semi-structured in-depth interviews, participant observation, and focus group discussions. Mostly, the interviews with the informants were conducted in their homes, offices, and at family events. I began with identifying and selecting informants for the study. I employed a purposive sampling technique and the eligibility criteria set out for this study was such that the informant:

1. must be women of Malay ethnicity;

2. must have had at least one experience with miscarriage defined by the FMGC (2017), as the spontaneous loss of a baby before the 24^th week of pregnancy.

3. must be working within the Klang Valley; and, 4. residing within the Klang Valley.

Since the interviews would essentially involve women’s recounts of their miscarriage experience, no age limit was set. Women who had experienced abortion or pregnancy losses beyond 24 weeks gestation were not considered for the study.

Unlike some medical conditions, miscarriage is not marked by any physical defects and signs. For this reason, employing a purposive snowballing sampling technique proved to be the most effective in identifying women who fit the study eligibility criteria. Thus, data collection was an ongoing process of selection until the

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last participant was interviewed. Table 1.1 illustrates the socio-demographic and miscarriage details of the 30 informants selected for the study.

In this study, 30 working Malay women, aged between 26 and 40 years old, were selected as informants for the study. They were all of Malay ethnic origin and Muslim.

The women interviewed were all highly educated, having had achieved at least a Diploma, with four women having postgraduate degrees. During the interviews, they mainly communicated in Bahasa Melayu, even though most of the women are proficient in English. Most of the informants were full-time government and private sector employees, ranging from professionals, managers, officers, and clerical staff. All informants worked and resided in the Klang Valley. At the time of the interview, three of the women selected were owners of personal online businesses, and therefore, worked from home. However, at the time of their miscarriages, they were working as an accountant, marketing executive, and lecturer.

All informants selected had at least one experience of miscarriage that had occurred within the first 20 weeks of pregnancy. During the data collection process, seven of the informants did not have any children at the time of the interview. Four of the informants were pregnant at the time of the interview. Of the 30 informants, 23 had one experience with miscarriage. The remaining seven informants had suffered multiple miscarriages that involved at least two consecutive miscarriages. One of the informants, Azira, had one child from her first pregnancy but sadly suffered six miscarriages, followed by two ectopic pregnancies. At the time of the interview, she shared how she was recently divorced from her husband of 18 years. She was the only divorcee among the informants.

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Table 1.1 Socio-demographic and miscarriage details of the 30 informants selected for the study.